Safety Mantra: Can’t not Don’t

“Don’t do this..” has never worked for safety in any industry. For example, in manufacturing, a machine called the punch press took many fingers of workers who were not responsive to warning notices and red lights etc. Safety was not achieved until the punch press was redesigned such that TWO hands were required on the buttons to start the action of the machine. Making sure the hands were being used to run the machine prevented hands from being inadvertently left inside the machine (Levinson, 2011). This is an example of CANT not DONT.

Safety is achieved by force function eg. can’t do it any other way but the right way. Worker vigilance is not reliable or sustainable. Some other examples of CANT not DONT include the SPIKERIGHT enteral system from Nestle which prevents a tube feeding from being connected to IV access. more—-

After the Dennis Quad incident, Baxter initially touted clinician vigilance as necessary for safety but then redesigned its high dose heparin to have a warning label that MUST be pulled off before entering the vial so no one can inadvertently give high dose heparin. Clinical vigilance is DONT but redesigning the package is closer to achieving CANT.

One final example given by Levinson (2011) involves the mandate that clinicians are always responsible for checking expiration dates. This is another human failure potential. Luckily some companies are stepping up to the plate, providing labels that can change color after a certain time. Timestrip.com makes labels that change color based on a time period or a temperature, taking the human memory out of the safety process. This label turns red.

**Think about your daily activities as a clinician or look around your environment and see what your DONTS are. Can any of them be replaced with CANTS? You just might save a life!

About this blog: You’ve heard of Leapfrog now there’s SafetyDog!

This blog will merge ideas from management, nursing, medicine and psychology (and many others) to offer a different view of patient safety. The author has a Masters in Industrial-Organizational Psychology, a graduate certificate in Error Science and Patient Safety and also a BSN in Nursing and has worked as an RN since 1985. All comments are welcome..you never know when one of your thoughts might save a life!

Patient Safety

IOM
Institute of Medicine..their 1999 report “To Err is human” started it all.

Leap Frog Group
The Consumer Reports for hospitals. Encouraging transparency and comparison of quality and safety.

ISMP
Institute for Safe Medication Practices. If you are looking for information on safe medication practices (and unsafe ones) they have great newsletters and other resources.

IHI
The Institute for Healthcare Improvement has an entire section on patient safety.

AHRQ
The Agency for Healthcare Research and Quality. Great site from the Department of Health and Human services. Contains research articles and safety guidelines and tools. The link is to Patient safety net

Healthcare Quarterly
Best practices and peer reviewed articles. Editor is a PhD from the University of North Carolina.